White Acres Wellness & Rehabilitation

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

individualized comprehensive assessment process. Policy- Residents are provided with the necessary care and services to maintain the highest practicable physical, mental, and social well-being level of in an environment that enhances qualify of life in the scope of a long-term care facility. Care and services are provided in a manner that consistently enhances self-esteem and self-worth. -Procedure- The IDT receives and review initial assessment information to ensure that members of the IDT interact with the residents in a manner that enhances self-esteem and self-worth, such as activities related bathing, grooming, dining, recreational and social opportunities.Record review of the facility End of Life Care Policy dated 08/2020, revealed, Purpose- To provide a process to assist the resident in fulfilling their spiritual, physical, and emotional needs, and to provide emotional support to families of residents with terminal illness. Policy- The facility will help residents maintain their dignity and provide comfort and security to residents in a caring environment. Coordination with Hospice - If hospice care was involved, the resident's care plan will reflect hospice interventions. Social Services Staff will coordinate with Hospice staff to ensure that the residents needs are communicated to the hospice. Social Services staff may include the hospice team in the resident's IDT conference.

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If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/18/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

White Acres Wellness & Rehabilitation

7304 Good Samaritan Court El Paso, TX 79912

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

had removed her gloves, entered the bathroom to wash her hands in the hand sink, and stated that the soap dispenser was empty. Hospice CNA stated she walked out of the bathroom and used hand sanitizer.During an interview on 08/18/25 at 10:25 AM, with the ADON, she stated when providing perineal care staff are to be washing their hands and putting on gloves. The ADON stated you start by cleaning the resident from front to back and make sure nothing gets soiled. The ADON stated then you throw away the soiled wipe and remove the gloves and clean your hands and reapply gloves. The ADON stated it would not be okay to be having dirty wipes on top of clean ones. The ADON stated not washing your hands and changing out your gloves could be a risk of infection. During an interview on 08/18/25 at 1:40 PM, with the DON, she stated she was the infection control preventionist. The DON stated when conducting perineal care, the staff had to wash their hands and talk to the resident letting them know what was going to happen. The DON stated all staff have to make sure they have their perineal care supplies ready. The DON stated you wash your hands and put on your gloves and open the brief and clean from front to back for females and males from the tip and down. The DON stated if there was any stool it would have to be cleaned first. The DON stated it was not okay to place dirty wipes on top of clean ones. The DON stated anything contaminated should not be touching anything else nor the same contaminated gloves should be touching anything. The DON stated gloves are to be replaced, thrown, and hand washing performed, and reapply new clean gloves. The DON stated it would be a risk of contamination. Record review of the facility Perineal Care Policy dated 06/2020, revealed, Purpose- To maintain cleanliness of the genital area, to reduce odor, and to prevent infection or skin breakdown. Policy- Perineal care was provided as part of a resident's hygienic program, am minimum of once daily and per resident need. 1. Wash hands. 2. Explain procedure to resident. 3. Gather equipment. 4. Provide Privacy. 5. Put on gloves. 6. Wash the pubic area (the region on the lower abdomen, just above the genitals, where the pelvis meets at the front). - A. For a female resident(s): i. Separate the labia (the inner and outer folds of the vulva, at either side of the vagina).

Wash the soapy washcloth/cleansing wipe, moving from front to back, on each side of the labia and in the center over the urethra (The tube through which urine leaves the body) and vaginal opening, using a clean washcloth/cleansing wipe for each stroke. ii. Rinse area, moving from front to back using a clean washcloth/cleansing wipe for each stroke. iii. Dry area moving from to back, using a blotting motion (gently dabbing or pressing an absorbent material onto a stain to soak up liquid without spreading it or damaging fibers) with towel. 7. Turn resident to side. 8. Wash, rinse and dry buttocks and peri-anal area without contaminating perineal area (the region of the body located between the anus and the external genital organs). 9. Remove wet linen. 10. Place dry linens or briefs or both underneath resident. 11. Reposition resident. 12. Remove gloves. Wash hands or use alcohol-based hand sanitizer. Note: Do not touch anything with soiled gloves after procedure (i.e. curtain, side rails, clean linen, call bell, etc.) 13. Put on clean gloves.

1. 14. Clean and return all equipment to tis proper place. 15. Place soiled linen in proper container. 16.

Remove gloves. 17. Wash hands. Record review of the facility Infection Prevention and Control Program Policy dated 10/24/22, revealed, Purpose-The ensure the facility established and maintained an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection in accordance with Federal and State requirements.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/18/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

White Acres Wellness & Rehabilitation

7304 Good Samaritan Court El Paso, TX 79912

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, interview, and record review the facility failed to ensure that each resident receives adequate supervision and assistance devices to prevent accidents for 1 (Resident #8) of 4 residents reviewed for accidents hazards.The facility failed to provide safe transfer assistance, using proper transfer techniques for Resident #8. CNA A and CNA B failed to secure the brakes on the mechanical lift prior to lifting Resident #8 off the wheelchair.This failure placed the resident at risk of injury from improper transfer techniques.The findings included:Record review of Resident #8's face sheet dated 08/18/25, revealed, admission on [DATE REDACTED] and re-admission on [DATE REDACTED] to the facility. Record review of Resident #8's facility history and physical dated 06/05/25, revealed, a [AGE] year-old male diagnosed with dementia, degenerative disease of the central nervous system (a group of disorders where nerve cells in the brain and spinal cord progressively lose function, leading to a decline in physical and cognitive abilities), and Complete trisomy 21 syndrome (a genetic disorder where a person has a complete extra copy of chromosome 21 in all their cells, resulting from an error during the formation of egg or sperm). Record review of Resident #8's quarterly MDS dated [DATE REDACTED], revealed, a BIMS was not taken to see the severity of impairment in cognition to be able to recall or make daily decision for Resident #8. It was not coded for mechanical lift. Functional abilities were dependent for roll left/right, sit to lying, lying to sitting on side bed, sit to stand, and chair/bed to chair transfer. Record review of Resident #8's care plan dated 05/17/25, revealed, ADLs self-care performance deficit related to down syndrome (a genetic condition where a person is born with an extra chromosome) and CVA (stroke occurs when a blood vessel in the brain becomes blocked or ruptures, cutting off blood flow to the brain). Transfer - extent/type may fluctuate within a day to day, depending on level of strength, pain, mood, etc. May require more staff assist or less. Resident was normally bedfast. Chair to bed dependent using 2 staff. On 08/06/25 at 8:30 AM a Facility Transfer, and ADLs Policy was requested from

the Administrator and DON via e-mail but did not provide one of each by the facility. During an observation and interview on 08/06/25 at 10:27 AM, with CNA A and CNA B, revealed, Resident #8 was going to be transferred from his wheelchair to his bed. CNA B was heard providing instructions to Resident #8 of what was going to happen. CNA A was positioning the mechanical lift in between Resident #8's wheelchair while CNA B was ensuring the sling was placed appropriately underneath Resident #8. Once the mechanical lift was in position CNA A and CNA B began to hook up the sling to the mechanical lift. CNA A, without locking

the mechanical lift brakes, began to lift Resident #8 into the air. CNA B moved the wheelchair and CNA A began to move Resident #8 over the bed and then began to lower Resident #8 down onto the bed. After the demonstration CNA A stated she had not locked the mechanical lift brakes. CNA B stated the mechanical lift brakes had to be locked or applied for the safety of Resident #8. CNA A stated not locking or applying

the lift brakes could have resulted in injury to Resident #8. During an interview on 08/18/25 at 10:30 AM, with the ADON, she stated the DON/ADONs provide training on transfers to the staff. The ADON stated the mechanical lift brakes had to be applied when lifting a resident into the air for safety. The ADON stated staff should be ensuring the mechanical lift brakes are on before lifting a resident into the air. The ADON stated

the risk could be injuries to the resident. During an interview on 08/18/25 at 1:40 PM, with the DON, she stated anytime a resident was going to be lifted into the air while using a mechanical lift the staff had to apply the mechanical lift brakes. The DON stated the negative impact of not applying the mechanical lift brakes could be the mechanical lift moving and possible injury to the resident. The DON stated the DON/ADONs were responsible for training staff on mechanical lifts.

Event ID:

Facility ID:

If continuation sheet